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Do paramedics have to transport everyone?

A paramedic from Victoria has asked me a question that I’ve been thinking about for sometime so I’m pleased to now get the opportunity to comment. My correspondent says:

I am a Paramedic with Ambulance Victoria, the statutory Ambulance service in Vic. It is an almost 100% belief amongst our paramedics that we MUST transport patients should they request it, regardless of if they need an ambulance or not. There are many documented cases of people using us purely as a taxi and a case I attended recently had a patient use us to get into the CBD then leave the hospital prior to assessment. He told us before he left that he had a business meeting to attend and can’t stay. My query to you is; Does an ambulance service have to transport anyone that requests transport to hospital, despite our professional assessment of their need?
Thanks for your time,

The answer to this question is simple, it is ‘no; there is no law that says an ambulance service has to transport everyone’.

Consent is a fundamental issue in medical care; we all know the basic principle that treatment cannot be given to someone without their consent; but that does not mean that all treatment that the person consents to, or wants, must be given. Some examples will make the point:
• A person may go to the doctor and ask for antibiotics, if the doctor forms the opinion that the illness is caused by a virus, he or she is not required to prescribe antibiotics;
• A person may go to the doctor with a myriad of symptoms and have decided that what they need is a kidney transplant. No amount of ‘patient consent’ would require, oblige or even permit the doctor’s to provide that treatment.

So just because a patient wants to go to hospital that in no way obliges the ambulance service, or a paramedic, to take them. So why do they do it? It’s clearly it’s a ‘cya’ response (I’ll leave it to others to explain that acronym for readers who don’t know what it means); that is it is a belief from the service, or individual paramedics, that transporting everyone is a low risk option. The belief has to be that if you don’t transport someone who ends up needing care, there will be all manner of difficulties with complaints, investigation and possible liability, and for government services ‘bad press’. On the other hand transporting everyone is a low risk option and leaves it to someone else, the hospital staff, to decide whether care is required.

Paramedics are however required to transport everyone if that is a term of their employment, that is if the ambulance service insists that is what is required. In that sense the law does require everyone to be transported as the law requires an employee to meet the terms and conditions of their employment and to comply with the lawful directions of their employer. So paramedics do have to transport everyone if that is what their employer directs them to do; but the law does not require ambulance services to impose that condition on their employees.

Apart from tying up ambulance resources, such an approach, if it is imposed by the ambulance service, fails to treat paramedics as professionals who can be trusted to make clinical judgments. One might hope that when paramedics are registered (if that occurs) and their registration is independent of their employer, then they will not only be able to, but will be expected to, exercise professional judgement including making a call on whether or not their services are required. That will, indeed, carry a risk that they will make the wrong call , and perhaps even a negligent call, but that would in fact reflect their status as a professional.

10 thoughts on “Do paramedics have to transport everyone?”

Could ambulance services come up with a set of guidelines that we could follow that have a set of “abnormal vital signs” and “complicated conditions (such as abdo pain etc)” that we must take but then allow us to refuse transport to those with silly complaints (like a sore toe) and normal vital signs?

absolutely the ambulance services can determine what services they provide and what they do not. Paramedic registration would further enhance the ability of paramedics to influence what is appropriate professional practice and so help ambulance services to make those guidelines and choices.

This is a common question. Behind the scenes there is a financial motive. While we, as paramedics dont like to waste time with “frequent flyers” or those that rort the system on a regular basis, each trip has a charge. This keeps the profit up. Someone pays, maybe not an individual…but someone does. In W.A. for example, the state ambulance service is a private company. Every person gets a bill. Ie, a quick pick up and drop off is a quick money spinner. This pays wages.
Like it or not, and use excuses such as duty of care or CYA…its all about money.
Have I not transported a patient, yes, many times. Drunks mainly or those that will not commit to going into hospital.
Bear in mind, anyone who is given medication in the ambulance is required by law under clinical guidelines to be assessed. Clinical guidelines are regulated by the health department in each state.

There are some important issues here; ambulance services may not be under a duty or have an obligation to transport everyone, but they do have a duty to respond to calls for assistance (see Kent v Griffiths [2000] 2 All ER 474). Not only must anyone who is given medication be assessed, so should everyone who calls for an ambulance to the extent that the person consents to being examined. Even if a patient refuses treatment it does not mean the service and paramedics do not have duties toward the person (see Neal v Ambulance Service of NSW [2008] NSWCA 346). Paramedics may not be under a duty to transport everyone, but further, they have no ability or authority to transport people who don’t want to be transported, so not transporting someone ‘will not commit to going into hospital’ is in effect not transporting someone who does not want the service being provided (that is the service is transport to hospital). That’s different to not transporting someone who says ‘I want to go to hospital’ but the paramedic determining there is no need, or even if they need to see a doctor, they don’t need ambulance transport.

As for clinical guidelines, the obligation upon paramedics is to follow reasonable directions of their employer so if the employer says that ‘anyone who is given medication in the ambulance is required … to be assessed’ then it is that obligation to follow the direction (contained in the guideline) that is the relevant law along with tort law that requires paramedics and ambulance services to act ‘reasonably’ and no reasonable paramedic would either administer medication, nor make a decision whether to transport a person or not, without assessing the patient and making a professional decision regarding their needs.

Hi Michael, Thank you for providing this blog, it is a wonderful place for some great legal discussion. With regard to the ‘transport all’ post, I recall when I first started 22 years ago the Ambulance Service Act 1990 (NSW) said we had to provide transport whether sick or not or something to that effect. Perhaps out thought processes about this issue comes from back then. I am not sure exactly when they ended our act and merged it into the Health Services Act 1997 (NSW) (something to do with corporations law and the federal government changes to industrial relations) but our requirement to transport ended then (if it existed before), and perhaps we haven’t kept up with our awareness of our operating act. I agree totally with you that this should be a professional decision making issue. Thanks again.

A slightly different perspective, and more about health policy implementation than legalities, is that if you have a relatively minor injury or illness and you get yourself to a hospital, your priority and care is sub-standard to those that are admitted via ambulance with the same injury.

Many in our circle of friends regret not calling an ambulance for an injury or illness. While we were either sufficiently self-ambulatory, or had friends and family that could help and not add to the ambulance service’s workload, in hindsight we believe we should have called one anyway, as the subsequent treatment processes were quite poor.

So what’s the position of a paramedic who attends someone who is injured, but it is of a sufficiently minor nature that they should be able to look after themselves?

Many people believe they will be seen sooner if they are taken to hospital by ambulance. This is a common misconception. All patients are treated according to their medical needs, whether they arrive by ambulance or not.
It is important to recognise that ambulances are available for saving lives and are not taxis. Calling an ambulance for non urgent conditions could cost someone their life.

“So what’s the position of a paramedic who attends someone who is injured, but it is of a sufficiently minor nature that they should be able to look after themselves?” That’s the question we’ve been answering, if paramedics are to be treated as professionals, they should be able to make judgments about whether their services are needed but they have to be made on proper clinical, professional grounds. I’m reminded of discussion in SES circles about responding to a request for assistance when there are apparently ‘healthy young blokes’ there, so why should SES volunteers climb on the roof. Making decisions on judgments about what people ‘should’ be able to do is not appropriate. In that SES context everyone is entitled to call for help, not just old age pensioners or single mums that we like to help because it accords with some idea of chilvary, so we have to respond to a request from the ‘fit young man’ as well. Secondly we have training in climbing on roofs and roof kits, they don’t so we shouldn’t want them climbing on roofs, falling off and getting injured. What’s that got to do with the ambulance scenario? That the judgment has to be on proper grounds, assuming that someone ‘should’ be able to look after themselves is not the same as thinking about, and discussing with them, whether they can look after themselves. Just as the SES can’t decide to provide services to people they think they ‘deserve’ their help, neither can paramedics. There is a fine, and often unclear line, between a professional judgement that the person who has called is not in fact injured and does not require transport or that they are ill or injured and need care, but an alternative means of transport is more appropriate. How those judgments can and should be made is a something for professionals, in their professional discussions, to consider and will be advanced if paramedics are registered. In any event not transporting someone because they ‘should be able’ to look after themselves (rather than they ‘can look after themselves’) would be very hard to justify.

My blog is automatically sent out via LinkedIN where a follower made this comment:

The key I think is to make sure that paramedics, making a decision not to transport based on a full clinical assessment as health care professionals, are unambiguously not held personally liable should the worst occur. Instead of a black and white of “needs help or not”, the more gray advice of “You need to go to your GP/pharmacist” might be more suitable. If the assessment is either “transport them, waste time, no risk”, or “don’t transport, save time, potentially high risk”, the zero risk option has a good chance of winning.

My reply was too long for LinkedIN so I’ve put it here:

I don’t agree with your proposition ‘”The key … is to make sure that paramedics … are unambiguously not held personally liable should the worst occur.’ The worst can occur in at least three possible circumstances:
1. Where, the ‘decision not to transport [is] based on a full clinical assessment’ and is reasonable in the circumstances for example, paramedics are called to a motor vehicle accident, they assess the patient who has no signs of injury and all assessments are normal. After discussion they advise the person transport is not required and half an hour later the person dies of a heart attack. In that case there is no liability as there is no negligence.
2. Where a decision is made negligently, for example paramedics are called to a patient who has overdosed on something that the paramedics believe is benign so they don’t transport but in fact it turns out that the material taken was in fact quite dangerous and the person did need care. Fail to transport because you didn’t understand, and then didn’t make enquiries as to the effect of the material taken, would be negligent.
3. Where the decision is not made in good faith, for example where paramedics are called to a ‘frequent flyer’ and dismiss his or her complaints as they are known to waste time, don’t assess the patient but in fact the person is in need of care.

Why should the paramedic not be liable in cases (2) and (3) above? Megan-Jane Johnstone, in her book Nursing and the Injustices of the Law (1994, W.B. Saunders/Bailliere Tindall) argued that nurses could not be seen as true professionals until they were being sued in their own right for their own professional decision making. Whilst that’s an affronting argument I think it has merit. If paramedics are going to be professionals, in particular if Australia adopts paramedic registration so that they are registered health professionals like doctors, nurses etc they have to take responsibility for their own decision making.

They cannot ‘unambiguously’ be not liable, as that assumes that questions of whether or not there was a full clinical assessment and a reasonable decision can be ‘known’ and not subject to disagreement. Courts are the ultimate tribunal to decide those issues so if, in my example 1, the paramedic says there was a ‘full clinical assessment’ but the family of the deceased disagree and the expert evidence for one side suggests that there would have been some sign or symptom that should have been detected, then those issues of fact have to be resolved. The paramedic may be found not to have been negligent, but it can’t be ‘unambiguous’ that is they have to go through the fact finding process to get to that result.

Where a paramedic (or a doctor, or anyone else) is performing their duties as an employee, it is the employer that is liable for their torts. In that sense paramedics who work for an ambulance service (private or government) will not be personally liable to pay any damages that may be awarded, but professional registration brings with it professional discipline, and that is one of the advantages that it does bring. People may not be able to sue the paramedic but they can complain if their conduct fails to meet professional standards (that is why professional registration is justified, it’s in the patient’s or public’s best interests). In that sense even if the ambulance service/employer is ultimately liable to pay damages (if any) the paramedic will still be ‘liable’ (to professional discipline) if their conduct warrants it. Now not every adverse result will warrant that but if paramedics are going to be professionals in their own right, they do have to take that on, so in fact the key of professionalism is that paramedics will be held to account (whether you call that liable or not) for their decisions and have to be willing to explain their choices.

It’s true that ‘if the assessment is either “transport them, waste time, no risk”, or “don’t transport, save time, potentially high risk”, the zero risk option has a good chance of winning” in fact I think it is winning which is why paramedics and ambulance services take the view that they have to transport everyone, hence my reference to it being a ‘cya’ (“cover your arse”) approach. It’s taking a very conservative approach to risk (we can never be in trouble if we transport everyone who wants to do and make the decision of what they need someone else’s problem) but it’s hardly professional conduct.

As for ‘Instead of a black and white of “needs help or not”, the more gray advice of “You need to go to your GP/pharmacist” might be more suitable’ is absolutely correct and that’s correct whether the paramedic thinks transport is not warranted or the patient refuses to go. In Neal v Ambulance Service of NSW the patient refused treatment and transport but that did not mean that the paramedics owed no further duty – it was not ‘take what I’m offering or nothing’. It was argued that the paramedics owed a duty to advise police who were taking Mr Neal into protective custody that he needed to go to hospital, and that would be true in other cases. Failure to advise the patient (or as in Mr Neal’s case, their carers) of what action was required could be negligent. (It should be noted the ambulance service was not held to have been negligent in Neal’s case, but for other reasons, and the question of whether or not it was a ‘breach of duty’ not to advise the police to take him to hospital was never resolved).

“I am a career paramedic employed by Ambulance Victoria. There are occasions where a request for ambulance attendance has been made, and after assessment treatment has commenced on the patient, the treatment has eased the signs and symptoms of the illness, or some cases reversed the condition. The patient after treatment may or may not require subsequent medical follow up but not necessarily at an emergency department immediately, it may in the opinion of treating paramedic require only a visit to the GP a some point in the near future as the patient’s long-term morbidity or even mortality will not be affected in the ensuing time. Does this change if the patient’s condition is identified but not life threatening for example a broken arm, is it required that they must be transported by ambulance? What if it is a condition such as for example only, hypoglycaemia, where the condition has been reversed through use of either invasive or non-invasive techniques. Again does this change if the use of schedule 4 drugs has been required to stabilise the patient and the immediate life threat or presenting chief complaint has been relieved, for example only, anti-emetics, naloxone for narcotic overdoses, broncho-dilators for asthmatics? Finally what if a schedule 8 drug has been administered as part of the treatment regimen. If your treatment has been invasive, is this a reason compelling me to transport? You have administered an S8 drug in good faith for analgesia but that is the only reason, and further assessment deems that the presenting condition is not life threatening and immediate presentation at an emergency department is not required, is it legal to advise the patient to continue to use over the counter analgesia according to the directions if the pain returns and seek GP advice at a point in the near future? All of this may well be a step too far.

There is no ‘legal’ answer to this. In short, the law requires paramedics to act as ‘reasonable paramedics’; to follow the lawful and reasonable directions of their employer and to comply with any statutory provisions such as the relevant poisons Act with regard to the use of scheduled drugs. The answer to the sort of scenarios, described above, will depend not on specific laws, but on what is considered ‘reasonable practice’ and what the various ambulance services dictate.

A critical feature of being a profession is that a profession sets its own standards based on reflective practice and on a sound scientific basis. Paramedicine is moving in that direction with university faculties and a developing field of paramedic science. It may be, at the moment, that it is not yet fully developed as a profession if what is acceptable paramedic practice remains a matter to be judged by others (in particular by doctors and medical panels (and note for example in Lithgow City Council v Jackson [2011] HCA 36 and also Ambulance Service of NSW v Worley [2006] NSWCA 102 where no paramedics were called to give evidence as to what can be expected from a reasonable paramedic. In Lithgow City Council v Jackson they didn’t even ask the paramedics involved about their decision making process or what they meant by notes on the case sheet!)

The health workforce is under stress and there are suggestions to use paramedics to relieve the burden on the workforce (see Health Workforce Australia, Extending the Role of Paramedics (http://www.hwa.gov.au/work-programs/workforce-innovation-and-reform/extended-scopes-of-practice-project/extending-role-of-paramedics)). Paramedics will only relieve demands on hospitals and nursing staff if they can in fact provide medical care out of hospital and either divert people to other services or provide the services they need. If a paramedic is going to say, reverse hypoglycaemia in a known diabetic, then if they can’t then say that the person does not need to go to hospital it is saving neither the health service, nor the patient’s time.

One option is to pretend that in these cases the patient ‘refuses’ treatment but that doesn’t help if the patient is in fact compliant and says ‘if you tell me I don’t need to go to hospital, I won’t but if you think I should, I will’. In any event ‘pretending’ you’re not transporting because the patient refused, rather than because the patient took your advice is unprofessional.

So, in short, there is no legal requirement to transport the patient. It may be negligent not to transport the patient but that will be a clinical judgement that should be determined by a professional body advised by appropriate science and relevant health policy and by employers, so in this context the ambulance service setting protocols and guidance for when it is appropriate not to transport patients. In the absence, however, of paramedics managing their own practice and scope of practice (that is in the absence of professional registration) what paramedics are allowed, and expected to do will be determined by their employer ambulance services.